. 2024 Nov 7;25:890. doi: 10.1186/s12891-024-08003-x

Table 1.

Literature review and primary data collection methodologies for the formative phase

Objective	Methods	Findings	How did it help?
*A literature review to understand challenges faced by patients and healthcare providers during post knee replacement rehabilitation period (1)*	Searched PubMed and Cochrane Library using keywords “knee replacement”, “physical rehabilitation”, “exercises”, “challenges”, “adherence”, “barriers”, “facilitators”, “experiences”, and “challenges” N = 36 relevant articles Articles with participants’ perception = 22 Article with healthcare provider’s perception = 14	Participants • Need for psychological & physical support after discharge from hospital, from family members & healthcare providers • Lack of motivation in initiating exercise schedule due to pain Healthcare providers • Delay in returning to routine activities due to lack of periodic monitoring	Identification of target behaviours along with the barriers & facilitators in following the target behaviour Designing data collection tools for mixed-methods cross-sectional survey
*A mixed-methods cross-sectional survey to identify challenges in adhering to rehabilitation protocols after knee replacement*	Information captured- • Specific challenges patients and healthcare providers faced during the recovery period and perception about teleconsultation for rehabilitation support (interview of healthcare providers) • A 22-item questionnaire to identify factors related to rehabilitation adherence (knee pain, support from family, focus on recovery, and scheduling of exercises) Quantitative interviews with patients = 79, consecutive sampling Qualitative interviews with patients = 8, convenience sampling Surgeons & physiotherapists = 10	• Male: 31 and Female: 48 • Facilitators- intake of pain medications for pain relief and support from family members during recovery phase • Barriers- missing exercises without any reason, unaware of the importance of exercises, and difficulty in commuting to health centre (1)	Contextual information on the identified target behaviour that can be addressed
*A systematic literature search on post-acute knee replacement physical therapy*	Searched systematic reviews on Epistemonikos (2) and PubMed on 8th October, 2021 with key words “Knee replacement”, “Knee arthroplasty”, “Rehabilitation”, “Physical therapy”, “Exercise”, and “Physiotherapy” Identified 36 relevant articles	Clinical practice guidelines (n = 3) (3, 4, 5), Systematic reviews of RCTs reporting evidence for various physiotherapy modalities (n = 28) and Systematic reviews of RCTs reporting evidence for various therapy plans and monitoring mechanisms (n = 30) • Cryotherapy beneficial in post-surgical pain reduction (6) • CPM (7), NMES (8), and TENS (9) little or no effect on pain and function at three months post-surgery • CPM not beneficial in improving ROM of knee joint (7) whereas closed and open kinetic progressive resisted exercises improved ROM as well as muscle strength of knee • Incorporating balance training exercises early recovery phase to improve balance, gait, and function (10) • Monitoring and individualized therapy plan for better patient satisfaction when compared to no monitoring (11) • No significant effect of type of therapy (e.g., aquatic therapy, ergometer cycling) on short- or long-term functional outcomes (12) • Telerehabilitation equally effective in reducing pain and improving function (13) compared to face-to-face • Telerehabilitation: Significant improvement in quality of life, patient satisfaction, and significant decrease in total rehabilitation cost	Developing post knee replacement physical rehabilitation protocol
*An e-survey to understand current physiotherapy practices post knee replacement*	Design- Cross-sectional Setting- Online Sample- Practising physiotherapists across India, snowball sampling Information captured- Using study specific questionnaire on therapeutic modalities, type of exercises, most common tools prescribed to patients after knee replacement, clinical parameters opt as progression criteria, perception on importance of prehabilitation and preoperative education for post knee replacement rehabilitation (Supplementary file- Table 1) Total responses- 158 Complete responses- 103	• Most used modality for pain relief- Cryotherapy (48%) and use of NEMS (17%) • Ankle, and hip exercises (85.3% and 87.6% respectively) included in the therapy protocol along with knee exercises • Open Kinetic chain, Closed kinetic Chain and combined advised “always” by 42-56% of respondents • Functional exercises “always advised”- walking outdoors (73%), stair climbing (65%) & sit-to-stand exercise (60%) • Most opted clinical parameters to monitor progress- ROM (99%) and muscle strength (98%) • Pre-surgery education advocated by all participants. Proposed topics for education listed in (Supplementary file- Table 2) • 12 to 25 contact sessions between physiotherapists & patients after first month of surgery • Preferred mode- Face-to-face followed by teleconsultation (33%)	Defining physiotherapy protocols based on current practice patterns
*A survey to assess level of digital literacy and home environment modifications of patients with knee replacement*	Information captured- Using study specific questionnaire on digital literacy, home environment, and expected support during recovery phase 56 participants, consecutive sampling	• Fifty-six participants (Male: 17 and Female: 39) • 3/4th owned a personal smart phone • Functions used “daily” with full confidence- Audio calling (86%) and entertainment (48%) • Functions rarely used with no confidence- E-Banking, email and e-shopping functions (Supplementary file-Fig. 1) • Home environment- western style toilet within their homes (100%), railings present inside house (12%) and in bathroom (14%). • Private physiotherapists support either at clinic or home (42%) due to inability to recall exercises and need for physical support during exercises	Digital literacy – Ensure ease of app interface and choice of patients who can enrol into the program, App manual Home modifications – Developing the contents of education materials
*A survey to assess health literacy of patients with knee replacement*	Information captured- Using Health literacy questionnaire on nine domains of health literacy The score of each of the nine domains ranged between 1–4 and 1–5 104 participants, consecutive sampling	• 104 participants (Male: 32 and Female: 72) • Highest score- Ability to actively engage with health care providers [mean 4.0 (SD 0.7)] • Lowest scores- sufficient information to manage their health [mean 2.1(SD 0.7)] and able to appraise available health information [mean 2.5(SD 0.7)(Supplementary file 1: Fig. 1)	Developing the contents of education materials
*A scoping review to identify features of existing technologies and to understand the perception of users about the technology for rehabilitation monitoring post-knee replacement (14)*	Searched EMBASE, Medline and PsycINFO via OVID and Cochrane trial for the studies published between 2001–2021, reporting use of mobile application or any other technology for monitoring rehabilitation. Search key terms- “Knee arthroplasty” “Knee replacement”, “mobile”, “web”, “remote sensor”, “computer”, “telerehabilitation”, “m-health” “mobile applications”, “digital technology” and “videoconferencing”. Literature search and screening along with the reference list of eligible articles: Rayyan Protocol of the review: 10.17605/osf.io/srxkc 105 relevant articles	Use of telerehabilitation methods: 64 studies, Validation studies of sensors for measuring range of motion (ROM) or gait parameters: 28 studies User perception: 38 studies. • Primary functions of remote rehabilitation: education and enablement of performing exercises, goal setting, measuring outcomes such as knee function, pain and ROM, monitoring progress, and communication • End-user involvement during the development stage of the intervention: 4 studies (15, 16, 17, 18) • High levels of satisfaction reported by healthcare providers in use of technology. Reason- reduction in workload, reliability of measurements aided by technology, and ease of reporting and tracking patient data (19, 20, 21) • Patients satisfaction with tele-monitoring- improve access to services, continued support after discharge from hospital without clinic visits, self-management & personalized care by providers (19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31) • Patients dissatisfaction- lack of in-person examination, and shorter consultation time (19, 27, 31) • Technology use greatly influenced by computer literacy (23, 32) • None of the technologies designed and implemented in lower-middle income countries	Identification of features and functions of mobile app End-user requirements Lack of evidence from lower-middle income countries context

Objective

Methods

Findings

How did it help?

A literature review to understand challenges faced by patients and healthcare providers during post knee replacement rehabilitation period (1)

Searched PubMed and Cochrane Library using keywords “knee replacement”, “physical rehabilitation”, “exercises”, “challenges”, “adherence”, “barriers”, “facilitators”, “experiences”, and “challenges”

N = 36 relevant articles

Articles with participants’ perception = 22

Article with healthcare provider’s perception = 14

Participants

• Need for psychological & physical support after discharge from hospital, from family members & healthcare providers

• Lack of motivation in initiating exercise schedule due to pain

Healthcare providers

• Delay in returning to routine activities due to lack of periodic monitoring

Identification of target behaviours along with the barriers & facilitators in following the target behaviour

Designing data collection tools for mixed-methods cross-sectional survey

A mixed-methods cross-sectional survey to identify challenges in adhering to rehabilitation protocols after knee replacement

Information captured-

• Specific challenges patients and healthcare providers faced during the recovery period and perception about teleconsultation for rehabilitation support (interview of healthcare providers)

• A 22-item questionnaire to identify factors related to rehabilitation adherence (knee pain, support from family, focus on recovery, and scheduling of exercises)

Quantitative interviews with patients = 79, consecutive sampling

Qualitative interviews with patients = 8, convenience sampling

Surgeons & physiotherapists = 10

• Male: 31 and Female: 48

• Facilitators- intake of pain medications for pain relief and support from family members during recovery phase

• Barriers- missing exercises without any reason, unaware of the importance of exercises, and difficulty in commuting to health centre (1)

Contextual information on the identified target behaviour that can be addressed

A systematic literature search on post-acute knee replacement physical therapy

Searched systematic reviews on Epistemonikos (2) and PubMed on 8th October, 2021 with key words “Knee replacement”, “Knee arthroplasty”, “Rehabilitation”, “Physical therapy”, “Exercise”, and “Physiotherapy”

Identified 36 relevant articles

Clinical practice guidelines (n = 3) (3, 4, 5), Systematic reviews of RCTs reporting evidence for various physiotherapy modalities (n = 28) and Systematic reviews of RCTs reporting evidence for various therapy plans and monitoring mechanisms (n = 30)

• Cryotherapy beneficial in post-surgical pain reduction (6)

• CPM (7), NMES (8), and TENS (9) little or no effect on pain and function at three months post-surgery

• CPM not beneficial in improving ROM of knee joint (7) whereas closed and open kinetic progressive resisted exercises improved ROM as well as muscle strength of knee

• Incorporating balance training exercises early recovery phase to improve balance, gait, and function (10)

• Monitoring and individualized therapy plan for better patient satisfaction when compared to no monitoring (11)

• No significant effect of type of therapy (e.g., aquatic therapy, ergometer cycling) on short- or long-term functional outcomes (12)

• Telerehabilitation equally effective in reducing pain and improving function (13) compared to face-to-face

• Telerehabilitation: Significant improvement in quality of life, patient satisfaction, and significant decrease in total rehabilitation cost

Developing post knee replacement physical rehabilitation protocol

An e-survey to understand current physiotherapy practices post knee replacement

Design- Cross-sectional

Setting- Online

Sample- Practising physiotherapists across India, snowball sampling

Information captured- Using study specific questionnaire on therapeutic modalities, type of exercises, most common tools prescribed to patients after knee replacement, clinical parameters opt as progression criteria, perception on importance of prehabilitation and preoperative education for post knee replacement rehabilitation (Supplementary file- Table 1)

Total responses- 158

Complete responses- 103

• Most used modality for pain relief- Cryotherapy (48%) and use of NEMS (17%)

• Ankle, and hip exercises (85.3% and 87.6% respectively) included in the therapy protocol along with knee exercises

• Open Kinetic chain, Closed kinetic Chain and combined advised “always” by 42-56% of respondents

• Functional exercises “always advised”- walking outdoors (73%), stair climbing (65%) & sit-to-stand exercise (60%)

• Most opted clinical parameters to monitor progress- ROM (99%) and muscle strength (98%)

• Pre-surgery education advocated by all participants. Proposed topics for education listed in (Supplementary file- Table 2)

• 12 to 25 contact sessions between physiotherapists & patients after first month of surgery

• Preferred mode- Face-to-face followed by teleconsultation (33%)

Defining physiotherapy protocols based on current practice patterns

A survey to assess level of digital literacy and home environment modifications of patients with knee replacement

Information captured- Using study specific questionnaire on digital literacy, home environment, and expected support during recovery phase

56 participants, consecutive sampling

• Fifty-six participants (Male: 17 and Female: 39)

• 3/4th owned a personal smart phone

• Functions used “daily” with full confidence- Audio calling (86%) and entertainment (48%)

• Functions rarely used with no confidence- E-Banking, email and e-shopping functions (Supplementary file-Fig. 1)

• Home environment- western style toilet within their homes (100%), railings present inside house (12%) and in bathroom (14%).

• Private physiotherapists support either at clinic or home (42%) due to inability to recall exercises and need for physical support during exercises

Digital literacy – Ensure ease of app interface and choice of patients who can enrol into the program, App manual

Home modifications – Developing the contents of education materials

A survey to assess health literacy of patients with knee replacement

Information captured- Using Health literacy questionnaire on nine domains of health literacy

The score of each of the nine domains ranged between 1–4 and 1–5

104 participants, consecutive sampling

• 104 participants (Male: 32 and Female: 72)

• Highest score- Ability to actively engage with health care providers [mean 4.0 (SD 0.7)]

• Lowest scores- sufficient information to manage their health [mean 2.1(SD 0.7)] and able to appraise available health information [mean 2.5(SD 0.7)(Supplementary file 1: Fig. 1)

Developing the contents of education materials

A scoping review to identify features of existing technologies and to understand the perception of users about the technology for rehabilitation monitoring post-knee replacement (14)

Searched EMBASE, Medline and PsycINFO via OVID and Cochrane trial for the studies published between 2001–2021, reporting use of mobile application or any other technology for monitoring rehabilitation.

Search key terms- “Knee arthroplasty” “Knee replacement”, “mobile”, “web”, “remote sensor”, “computer”, “telerehabilitation”, “m-health” “mobile applications”, “digital technology” and “videoconferencing”.

Literature search and screening along with the reference list of eligible articles: Rayyan

Protocol of the review: 10.17605/osf.io/srxkc

105 relevant articles

Use of telerehabilitation methods: 64 studies,

Validation studies of sensors for measuring range of motion (ROM) or gait parameters: 28 studies

User perception: 38 studies.

• Primary functions of remote rehabilitation: education and enablement of performing exercises, goal setting, measuring outcomes such as knee function, pain and ROM, monitoring progress, and communication

• End-user involvement during the development stage of the intervention: 4 studies (15, 16, 17, 18)

• High levels of satisfaction reported by healthcare providers in use of technology. Reason- reduction in workload, reliability of measurements aided by technology, and ease of reporting and tracking patient data (19, 20, 21)

• Patients satisfaction with tele-monitoring- improve access to services, continued support after discharge from hospital without clinic visits, self-management & personalized care by providers (19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31)

• Patients dissatisfaction- lack of in-person examination, and shorter consultation time (19, 27, 31)

• Technology use greatly influenced by computer literacy (23, 32)

• None of the technologies designed and implemented in lower-middle income countries

Identification of features and functions of mobile app

End-user requirements

Lack of evidence from lower-middle income countries context

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